1. E&MCODING: SCORE MEDICALE&MCODING: SCORE MEDICAL
DECISION MAKING THE WAYDECISION MAKING THE WAY
AN AUDITORWILLAN AUDITORWILL
TALLY YOUR MDM THE WAY THE AUDITORSTALLY YOUR MDM THE WAY THE AUDITORS
DODO
Jen Godreau, BA, CPC, CPEDCJen Godreau, BA, CPC, CPEDC
Co nte nt Dire cto rCo nte nt Dire cto r
Inhe althcare ’s Supe rco de rInhe althcare ’s Supe rco de r
je nnife rg @ supe rco de r. co mje nnife rg @ supe rco de r. co m

2. What Is the Table of Risk?What Is the Table of Risk?
 1 of 7 tables in the 1995 and 1997 E/M
Documentation and Coding Guidelines.
 1 of 3 preliminary tables that you can use
along with the problem categories table and
the type of data table, to determine the level of
decision-making

4. Why Should I Use the Sheets?Why Should I Use the Sheets?
 provide support for your physician’s code
selection
 self-audit tool to check your physicians’ levels
 Watch out: You might have to use a different
audit tool for some carriers.
 TrailBlazer (Medicare Part B carrier for Texas,
Virginia, Maryland and Delaware) has developed
its own counting system

6. How Does RiskTie Into MDM?How Does RiskTie Into MDM?
 Medical decision-making (MDM)
comprises three elements:
 Number of diagnoses or management options
 Amount and/or complexity of data to be reviewed
 Risk of complications and/or morbidity or
mortality
 To qualify for a given type of decision-
making the physician must meet or
exceed 2 of the 3 elements

7. How Should I Evaluate Type?How Should I Evaluate Type?
 You can’t read your physician’s mind
 They can help you see what was involved by
completely documenting the process
 include all diagnoses and any suspected
problems or concerns, including rule-outs
 Don’t overlook: You won’t code the rule-outs,
but documenting them shows a more involved
MDM type.

8. What Should I LookFor?What Should I LookFor?
 To weigh the type of risk, zoom in on 3
items.
 Diagnosis
 Status
 Risks, treatments or management
You can map these to the CMS medical
point-making system.

10. Score MDMLike a Pro -- Here’sScore MDMLike a Pro -- Here’s
HowHow
 You code it:
 An ENT sees a patient with a diagnosis of
otitis media (OM) and decides the patient
requires tubes. The physician orders no tests
and reviews no records. The patient is
scheduled for tympanostomy (69436,
Tym pano sto m y [re q uiring inse rtio n o f
ve ntilating tube ], g e ne ralane sthe sia ).

11. Classify Problem’s Status UsingClassify Problem’s Status Using
Table 1Table 1
 Follow these rules:
 If the ENT has previously treated the patient for
OM, CMS considers the problem established and
awards 2 points for an established problem that
is inadequately controlled, worsening or failing to
progress as expected
 If this is the first time the ENT is treating the
patient for OM, you should consider the diagnosis
a new problem, which is worth three points

12. Classify Problem’s Status UsingClassify Problem’s Status Using
Table 1Table 1
 Why is there a point difference?
 CMS expects that the decision-making for a
known problem is less than that of a new problem
 Who is the problemnew to?
 The sheet indicates “to the examiner”. The
problem has to be new to that provider. The
increased score for a new problem is given
because working up a new problem involves
more work than assessing a problem that is
established or familiar to the physician.

13. Classify Problem’s Status UsingClassify Problem’s Status Using
Table 1Table 1
 Is the problem self-limited or minor?
Examples of self-limited or minor on Table of Risks
 Cold
 Insect Bite
 Tinea Corporosis
 For cases involving a self-limited or minor
problem you still count the problem’s
status as self-limited or minor and assign
it 1 point, rather than giving it 3 points

14. Self-Limited or MinorSelf-Limited or Minor
 Defined as:
 “A problem that runs a definite and
prescribed course, is transient in
nature, and is not likely to
permanently alter health status OR
has a good prognosis with
management/compliance.”

15. Classify Problem’s Status Using TableClassify Problem’s Status Using Table
11
 CMS guidelines state,
 “The assessment of risk of the presenting problem(s)
is based on the risk related to the disease process
anticipated between the present encounter and the
next one.”
 Risk measures the chance of the patient
becoming worse from the time he leaves the
physician’s care to the next visit.
 A common cold carries minimal risk, consistent with
the definition of a minor or self-limited problem.

16. Example:Example:
 An established male patient previously diagnosed as a controlled-
diabetic presents with complaints of a runny nose and congestion
without any other symptoms.
 Ignoring the co morbidities and listing only the presenting problem
diagnosis ,will make the visit qualify for the lowest risk level.
 The physician should also consider the effect the patient’s diabetes has
on management options, and if the physician treats the condition, they
should report 250.00 (Diabe te s m e llitus witho ut m e ntio n o f co m plicatio n;
type IIo r unspe cifie d type , no t state d as unco ntro lle d) for addressing the
underlying disease.
 Documentation guidelines state, “Co morbidities/underlying diseases or
other factors that increase the complexity of medical decision making by
increasing the risk of complications, morbidity, and/or mortality should
be documented.”

17. Calculate Reviewed Data PointsCalculate Reviewed Data Points
Going back to our previous ENT OM case study:
You code it:
An ENT sees a patient with a diagnosis of otitis
media (OM) and decides the patient requires
tubes. The physician orders no tests and
reviews no records. The patient is scheduled
for tympanostomy (69436, Tym pano sto m y
[re q uiring inse rtio n o f ve ntilating tube ], g e ne ral
ane sthe sia).

18.  The ENT did not review any data so he receives a
0 in this table.
 Remember to map your CPT codes to the areas
listed in the Amount and/or Complexity of Data
Reviewed table.
 Give 1 point for clinical lab tests like urinalysis or a
strep test. (80000 series codes)
Don’t miss: The table counts medicine tests (90000
codes) separately. If a physician reviews an x-ray
and orders an ECG, give 1 point for each of these
tests.
Calculate Reviewed Data PointsCalculate Reviewed Data Points

19.  If the physician is coding the service like an x-ray,
allergy testing, or an ENG at this service or
another, they are already receiving credit for the
review in the test code.
 Give points for work the physician could not
otherwise get credit for.
 ei: a strep test that an outside lab is reading or an x-
ray that an outside radiologist reads
 “Do not report [E/M] services for test interpretation
and report.”
Don’t Double Dip!Don’t Double Dip!

20.  Frustrated with the extra time associated with
E/M services that involve an interpreter or
require a translator?
 The Key – Get your physician to write “Poor
historian” and then record who the historian is
and why the patient is not giving the history.
Example:
Cases involving a babysitter attempting to give
the history for a small child. If time doesn’t
dominate these encounters qualifying them for
time-based coding, consider giving a point in
this table for “decision to obtain history from
someone other than parent.”
Calculate Reviewed Data PointsCalculate Reviewed Data Points

21. Table of RiskTable of Risk
 Determining the ENT scenario’s level of risk
¤ minimal ¤ low ¤ moderate ¤ high ¤
 Here’s how: Select the risk level based on the
single highest element identified in the table of
risk’s three columns (1 of 3). Do not need one
element in each column. Instead assign the
patient’s risk using one element in the one
column that represents the highest level.

23.  To get started classify the level of these
elements:
 Presenting problem(s)
 Diagnostic procedures ordered
 Management options selected
Table of RiskTable of Risk

24. Lookto History forProblemLookto History forProblem
DetailsDetails
 OMPatient
 Should you classify OM with a decision for tubes as a
presenting problem that is stable chronic (low), acute
uncomplicated illness (low), or acute illness with
systemic symptoms (moderate)?
 If there is documented hearing loss, balance
dysfunction, speech/language delay, tympanic
membrane rupture, you could argue that it represents an
acute or chronic illness that may pose a risk to loss of
function, classifying the presenting problem as high.

25. Count Tests/Labs to ClassifyCount Tests/Labs to Classify
Column 2Column 2
 To calculate the diagnostic procedures level,
you’ll focus on any workup the
Otolaryngologist ordered.
 Because the physician in the OM case study
did not order or review any diagnostic
procedures, you have no circle in column two.

27. Check Hx When Weighing SurgeryCheck Hx When Weighing Surgery
RiskRisk
 Best bet: Before selecting the management
options level, check if the patient has any
identified risk factors. This refers to the
patient’s unique medical history that might
affect the outcome.
 If the patient in our case has asthma, you would
circle "minor surgery with identified risk factors,"
instead of "minor surgery with no identified risk
factors," upping this category’s level from low to
moderate.

28. Jump to ‘High’ forRiskJump to ‘High’ forRisk
ExceptionsExceptions
 Table lists “diagnostic endoscopies with no identified risk
factors” as moderate risk and “diagnostic endoscopies
with identified risk factors” as high risk.
Warning: Don’t increase the risk factor just because the
patient’s undergoing a scope.
“Does the fact that an endoscope procedure has risks
associated with it make it a ‘high’ level for a diagnostic
procedure ordered, or would the patient need to have a
medical issue such as a recent heart attack to make it
a ‘high’ level?”

29. Jump to ‘High’ forRiskJump to ‘High’ forRisk
ExceptionsExceptions
Do this: Usually give a physician moderate risk credit for
ordering a scope. All patients undergoing an endoscopy
face a certain amount of risk, so the ordering of the
endoscopy is always the same.
Exception: If a patient has an underlying health condition,
such as a recent heart attack, that makes his service
more questionable, you should increase the risk factor
from “moderate” to “high”.
Because the risk for that patient is increased, you should
give the physician credit for “high” risk to represent
ordering a diagnostic endoscopy for a patient who has
identified risk factors.

30. Circle ‘Moderate’ forWeighingCircle ‘Moderate’ forWeighing
Medication RiskMedication Risk
 Givingsamples involves this sameprocess.
 How Does CPT Weigh Managing Drugs?
 The table of risk in the AMA-approved 1995
E/M guidelines lists prescription drug
management as a common clinical example of
moderate risk. The provider has to evaluate the
suitability of the patient for the medication and
weigh the benefits and risks.

31. Circle ‘Moderate’ forWeighingCircle ‘Moderate’ forWeighing
Medication RiskMedication Risk
 What Counts as Prescription/Drug?
 Giving samples with or without a prescription all falls under
prescription drug management. The process of prescription drug
management would include giving the patient the actual meds as
samples, the thought process and risk would remain the same as
writing it down on a piece of paper.
Example:
 A female patient has allergic rhinitis. The allergist gives her
samples of Astelin to try as needed. He tells the patient to call in
for a prescription if she feels the prescription helps. This case
constitutes prescription management.

32. Circle ‘Moderate’ forWeighingCircle ‘Moderate’ forWeighing
Medication RiskMedication Risk
 Where Do OTC Instructions Fall?
 lower level of risk if the encounter involves only over
the counter (OTC) meds. Risk assessment relates to
the disease process anticipated between the present
encounter and the next one.
 If the patient had not been given prescription
samples or had merely been instructed to use
over-the-counter drugs, there would be less risk
involved. The table of risk provides OTC drug
management as an example of low risk.

33. Identify RiskLevel With HighestIdentify RiskLevel With Highest
CircleCircle
 In our OM case the physician’s diagnosis of chronic otitis media with
effusion 381.3 (O the r and unspe cifie d chro nic no n-suppurative o titis
m e dia) and documentation support a chronic illness with progression,
and the child who is new to the ENT has no co morbidities.
 Do your circles equate to low or moderate risk? You only need the 1 item for
risk. Assign the level based on the highest circle.
 The highest level is moderate. Therefore, the OM case has a moderate risk
level.

34. Obtain Final Complexity ResultObtain Final Complexity Result
 To tally your whole MDM, enter the 3 tables’ scores in the Final Result
for Complexity table.
 Determine the final score using 2 out of the 3 elements. Circle a "3" in
the first row for a new patient with a worsening condition, "moderate" for
the highest level of risk, and “≤ 1 Minimal" in the third row for no work-up
ordered as follows:

35. Obtain Final Complexity ResultObtain Final Complexity Result
 Tally: Because the scenario involves two circles in one
column, you draw a line down that column, which
classifies the case as moderate complexity. This level of
medical decision-making can support a level-four new
patient office visit (99204, O ffice o r o the r o utpatie nt visit
fo r the e valuatio n and m anag e m e nt o f a ne w patie nt,
which re q uire s the se thre e ke y co m po ne nts: a
co m pre he nsive histo ry, a co m pre he nsive e xam inatio n
and m e dicalde cisio n-m aking o f m o de rate co m ple xity ).

36. How would you score a case in whichHow would you score a case in which
no column had two circles?no column had two circles?
 The Highmark auditing score sheet instructs you if no
column contains 2 or 3 circles to "draw a line down the
column with the second circle from the left."
 Example:
 A patient has allergic rhinitis that’s usually controlled with Allegra-D
but weather changes trigger the patient’s allergies, which
precipitates her sinusitis. The patient’s sinusitis is a new problem to
the pediatrician and he plans no additional work-up and orders no
tests. The patient, an adolescent, gives her own history. The
pediatrician has previously treated the patient’s allergies and writes
her a prescription telling her to fill it if after she finishes the samples
provided. She decides the Xyzal is decreasing her sinusitis and
allergic rhinitis exacerbations.

37. How would you score a case in whichHow would you score a case in which
no column had two circles?no column had two circles?
 Under Number of Diagnoses or Treatment Options assign the sinusitis 3 points for a new
problem with no work-up and the allergic rhinitis one point for an established, stable problem.
The 4 points for diagnoses counts as extensive.
 Give no points under Amount and/or Complexity of Data Reviewed. The teenager gives her
own history, and the physician orders no tests. No data equals minimal or low.
 Drawing a line down the column with the second circle from the left gives you moderate
complexity MDM. A level 4 established patient office visit (99214, Office o r o the r o utpatie nt visit
fo r the e valuatio n and m anag e m e nt o f an e stablishe d patie nt, which re q uire s at le ast two o f
the se thre e ke y co m po ne nts: a de taile d histo ry, a de taile d e xam inatio n, and m e dicalde cisio n-
m aking o f m o de rate co m ple xity …) contains MDM of moderate complexity.

38. Putting History, Exam, MDMPutting History, Exam, MDM
TogetherTogether
Example:
Whe n a patie nt co m e s into the o ffice
co m plaining o f che st pain, we o fte n o rde r lab
wo rk, an ECG, and se nd the patie nt to the
ho spital. The se instance s invo lve m o de rate to
hig h risk but we do no t pe rfo rm a co m ple te
re vie w o f syste m s (RO S) due to the pre se nting
pro ble m ’s e m e rg e nt nature .
 Willthe se be le ve l4 o r 5 e stablishe d patie nt
o ffice visits?

39.  Choose level based on the medically necessary
history, exam, and medical decision making (MDM)
that is performed and documented at each
encounter.
 Probable combos for a patient presenting with a
possible heart attack:
 detailed history + detailed/comprehensive exam + mod/high
MDM
 Established patient visit requires 2 of 3 key
components, the MDM, plus the amount of exam,
may ultimately determine whether the encounter is a
level 4 (99214) or 5 (99215).
Answer:Answer:

40. Breakdowns:
 Assuming chest pain is a new problem, you would
receive 4 points in the "Number of Diagnoses or
Treatment Options" area for the new problem to
provider with additional work-up planned on the
standard documentation worksheet.
 You would receive a point for ordering lab work and a
point for ordering the ECG for a total of 2 points in the
"Amount and/or Complexity of Data to be Reviewed"
section.
 Because the diagnoses level puts you at a high level
and the data amount is at a low level, the risk will
determine whether the MDM is high complexity (if risk
is high) or moderate complexity (if risk is moderate).
MDMMDM

41.  Indicate in your question that these scenarios do not involve
performing a complete ROS, which a comprehensive history
requires.
 History taking probably involves asking the patient about the
severity, duration, quality, context, etc. of the pain (history of
present illness [HPI]) and any past personal or family history
of heart disease (past medical, family, social history [PFSH]).
Therefore, your HPI will probably involve at least 4 (extended)
HPI elements and 1 (pertinent) PFSH element.
 At minimum ask questions about the constitutional and
cardiac systems. Reviewing 2-9 systems (extended) counts as
detailed ROS.
 Extended HPI + extended ROS + pertinent PFSH = detailed
history.
History:History:

42.  Now if you examine 8 or more systems -- such
as constitutional, eyes, ENT, detailed cardio,
respiratory, skin, neurological, and
psychological, you’ll be at a comprehensive
exam.
 If the severity didn’t allow for anything other than
constitutional (vitals, general appearance) and
detailed cardio, you may still be at a detailed
exam.
ExaminationExamination::

43. Save the Date!Save the Date!
Next Webinar will feature our OB coding guru,
Suzanne Leder!
Written OB Coding Alert coached by every Ob
coder’s favorite expert Melanie Witt.
On April 20, Tuesday @ 12:00 EST
Suzanne will be covering Icd-10 Coding
Basics packed with OB, cardio,
and other specialty examples.

45. Supercoder.com